Iatrophobic: Tox

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Wednesday, January 26, 2011

Tox

Tox Approach: Resus-RSI-DEAD

Drugs That Prolong QT

Beta Blocker Toxicity

CCB Toxicity

Dabigatran (Pradaxa) Toxicity

Digitoxin Toxicity

Paracetamol Toxicity

Thursday, August 26, 2010

Digoxin Toxicity

Indications for DigiFab (FDA label = pdf link)

1. Acute ingestion of 10mg or more in previously healthy adults or 4mg in a previously healthy children. Or a level of 10ng/mL or more

2. Chronic ingestion of 6 ng/mL (4 ng/mL in kids)

3. Life-threatening toxicity.

VT or VF
Progressive Bradycardia
2nd or 3rd AVB not responsive to atropine
K > 5.5 (6 in kids) with rapidly progressive s/s of Dig Tox. [in Circulation 2010, can give empiric DigiFab in acute Digoxin poisoning if K is >5]

Strategies for administration of Antidigoxin Fab (DigiFab)

1 vial of DigiFab (40mg) = neutralizes 0.5mg of Digoxin

ng/mL is the same as mcg/L

Life-threatening cardiac glycoside toxicity, DigiFab should be given (Class I, LOE B)

Known dose of digoxin taken, 2 vials of DigiFab = 1mg of Dig
If chronic dig tox or when dose taken of dig unknown: dig level x weight in kg = number of vials to be given
Life-threatening highly suspected Dig Tox where level could not be immediately obtained, administer empirically 10 to 20 vials

(Circulation, 2010;122:S829-S861) (pdf link here: Cardiac Arrest in Special Situation)

Adverse Effects of DigiFab:

1. Hypokalemia (due to reactivation of Na-K ATPase)

2. Worsening of CCF (due to withdrawal of inotropic effect of digoxin)

3. Rapid Ventricular response in AF (due to withdrawal of digoxin effect on AV node)

Notes:

Hyperkalemia is both a marker of severity of Dig Tox and associated with poor prognosis
After DigiFab administration, Dig level may misleadingly increase as DigiFab binds with Dig (Dig level measures both bound and free Dig) until DigiFab is eliminated from the body (may be several days or weeks if renal impairment). Free Dig is the one toxic
Dig shifts K from inside to outside cell = hyperkalemia, this may lead to increase urinary excretion of K so that patient has hyperkalemia but a whole body deficit of K. When DigiFab reverses dig tox, K shifts back into cell = rapid decline in K concentration.
Hypokalemia may occur rapidly and so K must be monitored especially the next few hours and corrected accordingly

CCB Toxicity

1. Bradycardia + Hypotension

2. Hyperglycemia -- treat with insulin

Beta Blocker Toxicity

1. Bradycardia + Hypotension

2. Hypoglycemia

Saturday, June 26, 2010

Antiarrhythmics
Class 1: ajmaline*, cibenzoline*, dihydroquinidine*, disopyramide, encainide*, flecainide, mexiletine, pirmenol*, procainamide, propafenone quinidine*
Class 3: almokalant*, amiodarone, azimilide*, bretylium, dofetilide*, dronedarone*, d-sotalol*, ersentilide*, ibutilide*, nifekalant*, sematilide*, sotalol, terikalant*

Anti-anginals/vasodilators
bepridil*, lidoflazine*, prenylamine*, ranolazine, terodiline*, vardenafil

Anti-hypertensives
indapamide, isradipine, moexipril/hydrochlorthiazide, nicardipine

Antihistamines
astemizole*, azelastine, diphenhydramine, ebastine*, hydroxyzine, terfenadine*

Serotonin agonists and antagonists
cisapride*, dolasetron, granisetron, ketanserin*, ondansetron

Antimicrobials
Macrolide antibiotics: azithromycin, clarithromycin, erythromycin, roxithromycin*, spiramycin, telithromycin
Quinolone antibiotics: ciprofloxacin, gatifloxacin*, gemifloxacin*, grepafloxacin*, levofloxacin, moxifloxacin, ofloxacin, sparfloxacin*
Antifungals: cotrimoxazole, fluconazole (caution with itraconazole), ketoconazole, voriconazole
Others: pentamidine, trimethoprim sulfa (bactrim)
Antiviral: foscarnet (HIV)

Antimalarials
amantidine, chloroquine, halofantrine*, quinine

Psychiatric drugs
Tricyclic antidepressants: amitriptyline, amoxapine*, clomipramine, desipramine*, doxepin, imipramine, nortriptyline, protriptyline*, trimipramine
Phenothiazines: chlorpromazine, fluphenazine, prochlorperazine, thioridazine*, trifluoperazine
Others: atomoxetine, citalopram, clozapine, droperidol*, fluoxetine, haloperidol, levomethadyl*, lithium, maprotiline, mesoridazine, methadone, paroxetine, pericycline, pimozide, quetiapine, risperidone, sertindole, sertraline, trazodone, venlafaxine, zimeldine*, ziprasidone

Anticonvulsant
felbamate*, fosphenytoin (prodrug of phenytoin)

Anti-migraine
naratriptan, sumatriptan, zolmitriptan

Anti-cancer
arsenic trioxide, geldanamycin*, sunitib, tacrolimus, tamoxifen

Others
alfuzosin, chloral hydrate, clobutinol*, domperidone, galantamine, octreotide, organophosphates*, perflutren lipid microspheres, probucol, solifenacin, tizanidine, tolterodine, vasopressin

Stimulant drugs
Some cold remedies contain these drugs so it is important always to check the label.
adrenaline (epinephrine), amphetamine, cocaine, dexmethylphenidate, dobutamine, dopamine, ephedrine, fenfluramine, isoprenaline (isoproterenol), levalbuterol, metaproterenol, methylphenidate, midodrine, norepinephrine (noradrenaline), phentermine, phenylephrine, phenylpropanolamine, pseudoephidrine, ritodrine, salbutamol (albuterol), salmeterol, sibutramine, terbutaline

Source: Sads.org.uk

Monday, June 21, 2010

Dabigatran Overdose

http://www.thepoisonreview.com/2011/06/18/dabigatran-etexilate-a-new-challenge-for-emergency-physicians-and-toxicologists/

PCC: Protein Complex Concentrate - effective in reducing anticoagulation effect
FEIBA: Factor Eight Inhibitor Bypass Activity - very potent PCC combination that has activated clotting factors, so this may be one thing to consider, but clearly there is a paucity of clinical data about how to best do this

Sunday, June 6, 2010

Toxicology Approach

Toxicology

Risk assessment-based Approach: (Murray)

Resus-RSI-DEAD

Resuscitation (ABCDE)

ABC
Detect and correct (Hypogly, Sz, Hyper/hypothermia)
Emergency Antidote Administration

Risk Assessment (ADTCP)

Agent
Dose
Time since ingestion
Clinical features and course
Patient factors (weight and co-morbidities)

Supportive care and monitoring

Investigations

Screening: 12 lead ECG, paracetamol
Specific

Decontamination

Enhanced Elimination

Antidotes

Disposition

-----

RESUSCITATION

- acute poisoning associated with good neuro outcome (vs cardiac arrest in older patients) even after prolonged resus (hours)

- continue resus while obtaining expert advice

- cardiopulmonary bypass has been successful in some cases

- resus + supportive care are the priority NOT skin/GI decontamination

ABC

- with focus on AMS, loss of airway reflex, hypotension

- GCS <12 associated with increased risk of aspiration

AIRWAY

1. Airway Compromise

Mech: Corrosive injury to oropharynx

Agents: Alkalis, Acids, Glyphosate, Paraquat

Comments:

- Stridor, dysphagia and dysphonia indicate airway injury and potential for imminent airway compromise

- Early ET intubation or surgical airway often required

BREATHING

1. Acidosis/Acidemia

Mech: various

Agents: Ethylene glycol, Methanol, Salicylates

Comments:

- Until late in the clinical course there is usually prominent respiratory compensation

- Intubation and ventilation at standard settings may worsen acidemia and precipitate rapid clinical deterioration, if not death

- Avoid normo- or hypoventilation

- Maintain hyperventilation and consider bolus IV NaHCO3 1-2 mmol/kg to prevent worsening of acidemia

2. Hypoventilation

Mech: Opioid mu receptor stimulation

Agents: Opioids

Comments: Prompt administration of naloxone may obviate need for intubation and ventilation

3. Respiratory Failure

Mech: Cholinergic crisis

Agents: Carbamates, Nerve agents, OrganoPO4

Comments: Rapid administration of atropine by serial doubling of atropine dose to achieve dry respiratory secretions may restore adequate oxygenation

4. Acidosis, Hypoxaemia, Multi Organ Failure (MOF)

Mech: Oxygen-free radical mediated cellular injury, particularly type II pneumocytes

Agents: Paraquat

Comments:

- Avoid supplemental oxygen

- If hypoxia occurs, titrate supplemental oxygen to maintain oxygen saturation of ~ 90% or PaO2 60mmHg

CIRCULATION

1. Ventricular fibrillation

Mech: Hypocalcaemia

Agents: Hydroflouric acid ingestion or massive cutaneous burn

Comments:

- Defibrillation alone unlikely to be efficacious

- Bolus IV calcium (eg 60-90 mL of 10% calcium gluconate) repeated as required every 2 minutes until defibrillation restores perfusing rhythm

2. Ventricular tachycardia

Mech: Fast Na+ channel blockade

Agents: Chloroquine, Cocaine, Flecainide, Local anaesthetic agents, Procainamide, Propranolol, Quinine, TCA

Comments:

- Cardioversion or defibrillation unlikely to be efficacious

- Urgently intubate and hyperventilate

- Bolus IV NaHCO3 1-2 mmol/kg repeat every 1-2 minutes until restoration of perfusing rhythm

- Do not await serum pH determination prior to intubation and NaHCO3 boluses

- Lignocaine is third-line therapy when pH is established at >7.5

- Amiodarone and Vaughn Williams type 1a antiarrhythmics (eg procainamide) are contraindicated

3. Ventricular ectopy/tachycardia

Mech: Halogen-induced myocardial sensitisation to catecholamines

Agents: Chloral hydrate, Organochlorines

Comments:

- Cardioversion or defibrillation unlikely to be efficacious

- Administer IV beta-blockers, titrate to ectopy response

4. SVT

Mech: Adenosine antagonism

Agents: Theophylline

Comments: Urgent haemodialysis

5. Tachycardia

Mech: Central and peripheral sympathomimetic response

Agents: Amphetamines, Cocaine

Comments:

- Beta-blockers contraindicated

- Administer IV benzodiazepines, titrated to gentle sedation and HR control

6. Asystole, Bradycardia, Tachycardia

Mech: Na+/K+ ATPase pump inhibition

Agents: Digoxin

Comments:

- Usual resuscitative interventions futile

- Digoxin-specific antibodies

7. Bradycardia, Hypotension, Conduction defects

Mech: Calcium Channel blockade

Agents: CCB

Comments:

- Atropine and pacing unlikely to be efficacious

- Bolus IV Calcium (eg 60 mL of 10% calcium gluconate) may provide temporary haemodynamic stability by increasing HR and BP, while other treatments are organised

- High-dose insulin-dextrose therapy

8. Refractory hypotension

Mech: Various

Agents: Beta-blockers, CCB, local anaesthetics

Comments: High-dose insulin-dextrose therapy

9. Hypertension

Mech: Central and peripheral sympathomimetic response

Agents: Amphetamines, Cocaine

Comments:

- Beta-blockers contraindicated

- Administer IV benzodiazepines, titrated to gentle sedation and HR control

- If further treatment necessary, use titratable agents like:

GTN, Nitroprusside, Phentolamine

10. ACS

Mech: Central and peripheral sympathomimetic response

Agents: Amphetamines, Cocaine

Comments:

- Beta-blockers contraindicated

- Benzo

- GTN

- Antiplatelet adn anticoagulation therapy if no neurological deficits (otherwise cranial CT first)

- Reperfusion therapy along conventional lines

OTHER

1. Hyperkalaemia

Mech: Na+/K+ ATPase pump inhibition

Agents: Digoxin

Comments:

- Calcium salts contraindicated

- Digoxin-specific antibodies

2. Hypoglycaemia

Mech: Hyperinsulinaemia

Agents: Sulfonylureas

Comments:

- difficult to maintain euglycaemia with dextrose alone

- Ocreotide administration obviates need for dextrose supplementation

3. Refractory Seizures

Mech: Inhibition of GABA production

Agents: Isoniazid

Comments: IV pyridoxine: 1 gram per gram of isoniazid ingested, up to 5 grams

4. Seizures

Mech: Adenosine antagonism

Agents: Theophylline

Comments: Urgent haemodialysis

Detect and Correct Seizures

- Toxic seizures are generalised

- Usually controlled by benzos (diazepam, midazolam, lorazepam or clonazepam)

- most commonly caused in Australasia by:

1. Venlafaxine

2. Bupropion

3. Tramadol

4. Amphetamines

- focal/partial seizure is either a complication of poisoning or needs further consideration of non-tox cause

- 2nd line: Barbiturate

- 3rd line: Pyridoxine due to INZ poisoning

- Phenytoin is contraindicated for toxic seizures

Detect and Correct Hypoglycaemia

- if <4 mmol/L = give 50-50 (50 mls of 50% Dextrose), 5mL/kg of 10% Dextrose in kids

- Associated with:

1. Insulin and Sulfonylurea OHA

2. Beta-blockers

3. Quinine

4. Chlorquine

5. Salicylates

6. Valproic acid

Detect and Correct Hyper-/Hypothermia

- Hyperthermia is associated with life-threatening poisonings and poor outcome

- >38.5'C: needs continuous core-temperature monitoring

- >39.5'C: emergency to intervene and prevent MOF and neuro injury; NM paralysis with intubation and ventilation helps to stop muscle-generated heat production and rapid reduction of temperature

- Profound hypothermia (<29'C core): mimics or cause cardiac arrest: coma, fixed pupils, brady (usually Af), hypotension; Aggressive exogenous rewarming while CPR. Most effective is CP bypass. Alternative is pleural lavage through intercostal catheter with large volumes of fluid warmed to 40-45'C.

Emergency Antidote Administration

- sometimes indicated during resus

- examples: DANS

1. Sodium Bicarb for TCA

2. Naloxone for Opioids

3. Atropine for OrganoPO4

4. Digoxin-specifc antibodies for Digoxin with cardiovascular compromise

RSI

Risk Assessment (ADTCP)

1. Agent

2. Dose and type (eg ?sustained release)

3. Time since ingestion:

eg. TCA life threats occur within 6 hours (usu. within 2 hours), therefore low-risk patients can be identified 6 hours post ingestion)

4. Clinical features and course/progress

5. Patient factors (weight and co-morbidities)

Backup history:

1. Ask ambulance officers or family to search for agents

2. Counting missing tablets

3. Checking medical records for previous prescriptions

4. Question relatives about agents available to patient

Wednesday, December 3, 2008

Paracetamol Overdose

Overdose is 150 mg/kg (7.5, 9, 10.5 gram for 50, 60, 70 kg patient respectively)
Phase I:
- 12-24 hours
- GI symptoms, N/V, anorexia, diaphoresis, pallor
- coma is rare
- most patients recover and does not go beyond Phase I
Phase II
- if toxicity continues, this is the latent phase of up to 48 hours
- Symptoms abate and patient feels better BUT
  rising and striking levels of AST/ALT, PT/INR, bilirubin, lactate, phosphate
- RUQ pain due to liver enlargement and tenderness
- most patients does not go beyond this phase
Phase III
- rare, serious hepatic necrosis; 3-5 days after ingestion
- + jaundice, confusion, stupor, coagulation defect, hypoglycemia, encephalopathy, renal failure, cardiomyopathy
- death if it occurs is due to fulminant hepatic failure
- mortality rate for toxic level without treatment is 3-4%
Paracetamol metabolism: in the liver
- 3 pathways for metabolism; (1) and (2) are major
(1) Glucoronidation: glucoronide conjugate (not toxic) -> cleared by the kidneys
(2) Sulfation: sulfate conjugate (not toxic) -> cleared by the kidneys
(3) Cytochrome p450: NAPQI (N-Acetyl P-benzoQuinone Imine) (toxic) -> conjugates with sulfhydryl group of glutathione -> excreted to kidneys

OD: glutathione is saturated with lots of NAPQI and is depleted
NAPQI is toxic to liver = hepatoxicity and nephropathy
N-acetylcysteine (Mucomyst, Parvolex): precursor of Glutathione
Guidelines for Management of AOD (pdf)
Acetaminophen level
- take assay at 4 hours post-ingestion or ASAP if more than 4 hours
- above 200 ug/mL at 4 hours or 50 ug/mL at 12 hours = hepatotoxic
- Rumack-Matthew normogram: in order to err on the safe side, treatment line is drawn 25% below Rumack-Matthew line
- if below treatment line, NAC is unnecessary, or if already started, may discontinue
- if above treatment line, NAC complete course should be given even subsequent levels are below treatment line
- If a patient presents within 4 hours, withhold NAC until levels are out, PROVIDED that initiation of treatment is not delayed beyond 8 hours post-ingestion
- If a patient presents more than 8 hours, start NAC REGARDLESS of amount ingested. Do not wait for assay.
Management: ABCDEFG
(1) Activated Charcoal: 50 g if less than 4 hours ( >2 hours, data is limited)
- 1g/kg, resuspended with water to achieve 25% concentration, dose is 10:1 ratio of activated charcoal to toxin
- not absorbed: PHAILS
- Pesticides, Potassium
- Hydrocarbons
- Acids, Alkalis, Alcohol
- Iron, Insecticides
- Lithium
- Solvents
(2) N-acetylcysteine:
IV: total of 300 mg/kg in 24 hours
- 150 mg/kg + 200 mL 5% Dextrose in 15-60 mins
- 50 mg/kg + 500 mL 5% Dextrose in 4 hours
- 100 mg/kg + 1L 5% Dextrose in 16 hours
  = anaphylactoid reaction: PFUN (Pruritus, Flushing, Urticaria, Nausea, etc)
  Tx: Give slower
Oral: 140 mg/kg LD, then 17 doses of 70 mg/kg at 4-hour intervals
- total duration: 72 hours
LABS
- healthy, asymptomatic patient presenting early, only acetaminophen level
- in symptomatic or with elevated acetaminophen, ALT and AST, then daily
- in patients with liver injury: bilirubin, PT/INR, creatinine, BUN, electrolytes, blood glucose, lactate, phosphate, pH tests
- For Extended Release tablets: take it at 4 hours post-ingestion as there is no protocol, but some do a second level 4-6 hours after first assay
  - if either is above treatment line, start NAC
  - if either is below, discontinue NAC if already started

Special considerations:
- Children below 6yo, hepatotoxicity is rare due to different metabolism, same approach but different dose
- Pregnant: treat as non pregnant although NAC enters placental barrier
- >24 hours, ALT/AST should be taken; IV NAC improves survival for those on fulminant hepatic failure; Rumack-Matthew is useless
- Alcoholics: more prone to hepatotoxicity, but same approach
- Repeated supratherapeutic (chronic) OD: ingestion of toxic amounts over a period of longer than 8 hours
  - Rumack-Matthew is useless
  - NAC should be given if assay is >10 mg/L or with liver injury (AST/ALT)
  - NAC for 12 hours, then evaluate
  - may discontinue if clinically well, AST/ALT improving, assay <10>

	Adrenaline (Epinephrine)		Stimulant
	Ajmaline*		Antiarrhythmic (Class 1)
	Alfuzosin		Alpha1-blocker
	Almokalant*		Antiarrhythmic (Class 3)
	Amantidine		Antimalarial
	Amiodarone		Antiarrhythmic (Class 3)
	Amitriptyline		Psychiatric drug - Tricyclic antidepressant
	Amoxapine*		Psychiatric drug - Tricyclic antidepressant
	Amphetamine		Stimulant
	Arsenic trioxide		Anti-cancer
	Astemizole*		Antihistamine
	Atomoxetine		Psychiatric drug - Other
	Azelastine		Antihistamine
	Azimilide*		Antiarrhythmic (Class 3)
	Azithromycin		Antibiotic - Macrolide
	Bepridil*		Anti-anginal / vasodilator
	Bretylium		Antiarrhythmic (Class 3)
	Chloral hydrate		Sedative
	Chloroquine		Antimalarial
	Chlorpromazine		Psychiatric drug - Phenothiazine
	Cibenzoline*		Antiarrhythmic (Class 1)
	Ciprofloxacin		Antibiotic - Quinolone
	Cisapride*		Serotonin agonist / antagonist
	Citalopram		Psychiatric drug - Other
	Clarithromycin		Antibiotic - Macrolide
	Clobutinol*		Other
	Clomipramine		Psychiatric drug - Tricyclic antidepressant
	Clozapine		Anti-psychotic
	Cocaine		Stimulant
	Cold remedies		May contain stimulant drugs - always to check the label
	Cotrimoxazole		Antibiotic - Antifungal
	d-sotalol*		Antiarrhythmic (Class 3)
	Desipramine*		Psychiatric drug - Tricyclic antidepressant
	Dexmethylphenidate		Stimulant
	Dihydroquinidine*		Antiarrhythmic (Class 1)
	Diphenhydramine		Antihistamine
	Disopyramide		Antiarrhythmic (Class 1)
	Dobutamine		Stimulant
	Dofetilide*		Antiarrhythmic (Class 3)
	Dolasetron		Serotonin agonist / antagonist
	Domperidone		Other
	Dopamine		Stimulant
	Doxepin		Psychiatric drug - Tricyclic antidepressant
	Dronedarone*		Antiarrhythmic (Class 3)
	Droperidol*		Psychiatric drug - Other
	Ebastine*		Antihistamine
	Encainide*		Antiarrhythmic (Class 1)
	Ephedrine		Stimulant
	Ersentilide*		Antiarrhythmic (Class 3)
	Erythromycin		Antibiotic - Macrolide
	Felbamate*		Anticonvulsant
	Fenfluramine		Stimulant
	Flecainide		Antiarrhythmic (Class 1)
	Fluconazole		Antibiotic - Antifungal
	Fluoxetine		Psychiatric drug - Other
	Fluphenazine		Psychiatric drug - Phenothiazine
	Foscarnet (HIV)		Antibiotics - Antiviral
	Fosphenytoin (prodrug of Phenytoin)		Anticonvulsant
	Galantamine		Inhibitor (dementia, Alzheimer's)
	Gatifloxacin*		Antibiotic - Quinolone
	Geldanamycin*		Anti-cancer
	Gemifloxacin*		Antibiotic - Quinolone
	Granisetron		Serotonin agonist / antagonist
	Grepafloxacin*		Antibiotic - Quinolone
	Halofantrine*		Antimalarial
	Haloperidol		Psychiatric drug - Other
	Hydroxyzine		Antihistamine
	Ibutilide*		Antiarrhythmic (Class 3)
	Imipramine		Psychiatric drug - Tricyclic antidepressant
	Indapamide		Anti-hypertensive
	Isoprenaline (Isoproterenol)		Stimulant
	Isradipine		Anti-hypertensive
	Itraconazole		Antibiotic - Antifungal
	Ketanserin*		Serotonin agonist / antagonist
	Ketoconazole		Antibiotic - Antifungal
	Levalbuterol		Stimulant
	Levofloxacin		Antibiotic - Quinolone
	Levomethadyl*		Psychiatric drug - Other
	Lidoflazine*		Anti-anginal / vasodilator
	Lithium		Anti-mania
	Maprotiline		Psychiatric drug - Other
	Mesoridazine		Psychiatric drug - Other
	Metaproterenol		Stimulant
	Methadone		Psychiatric drug - Other
	Methylphenidate		Stimulant
	Mexiletine		Antiarrhythmic (Class 1)
	Midodrine		Stimulant
	Moexipril / Hydrochlorthiazide		Anti-hypertensive
	Moxifloxacin		Antibiotic - Quinolone
	Naratriptan		Anti-migraine
	Nicardipine		Anti-hypertensive
	Nifekalant*		Antiarrhythmic (Class 3)
	Norepinephrine (Noradrenaline)		Stimulant
	Nortriptyline		Psychiatric drug - Tricyclic antidepressant
	Octreotide		Other
	Ofloxacin		Antibiotic - Quinolone
	Ondansetron		Serotonin agonist / antagonist
	Organophosphates*		Other
	Paroxetine		Anti-depressant
	Pentamidine		Antibiotic - Other
	Perflutren lipid microspheres		Other
	Pericycline		Psychiatric drug - Other
	Phentermine		Stimulant
	Phenylephrine		Stimulant
	Phenylpropanolamine		Stimulant
	Pimozide		Psychiatric drug - Other
	Pirmenol*		Antiarrhythmic (Class 1)
	Prenylamine*		Anti-anginal / vasodilator
	Probucol		Other
	Procainamide		Antiarrhythmic (Class 1)
	Prochlorperazine		Psychiatric drug - Phenothiazine
	Propafenone		Antiarrhythmic (Class 1)
	Protriptyline*		Psychiatric drug - Tricyclic antidepressant
	Pseudoephidrine		Stimulant
	Quetiapine		Psychiatric drug - Other
	Quinidine*		Antiarrhythmic (Class 1)
	Quinine		Antimalarial
	Ranolazine		Anti-anginal / vasodilator
	Risperidone		Psychiatric drug - Other
	Ritodrine		Stimulant
	Roxithromycin*		Antibiotic - Macrolide
	Salbutamol (Albuterol)		Stimulant
	Salmeterol		Stimulant
	Sematilide*		Antiarrhythmic (Class 3)
	Sertindole		Psychiatric drug - Other
	Sertraline		Anti-depressant
	Sibutramine		Stimulant
	Solifenacin		Other
	Sotalol		Antiarrhythmic (Class 3)
	Sparfloxacin*		Antibiotic - Quinolone
	Spiramycin		Antibiotic - Macrolide
	Sumatriptan		Anti-migraine
	Sunitib		Anti-cancer
	Tacrolimus		Anti-cancer
	Tamoxifen		Anti-cancer
	Telithromycin		Antibiotic - Macrolide
	Terbutaline		Stimulant
	Terfenadine*		Antihistamine
	Terikalant*		Antiarrhythmic (Class 3)
	Terodiline*		Anti-anginal / vasodilator
	Thioridazine*		Psychiatric drug - Phenothiazine
	Tizanidine		Other
	Tolterodine		Bladder antispasmodic
	Trazodone		Psychiatric drug - Other
	Trifluoperazine		Psychiatric drug - Phenothiazine
	Trimethoprim sulfa (bactrim)		Antibiotic - Other
	Trimipramine		Psychiatric drug - Tricyclic antidepressant
	Vardenafil		Anti-anginal / vasodilator
	Vasopressin		Other
	Venlafaxine		Psychiatric drug - Other
	Voriconazole		Antibiotic - Antifungal
	Zimeldine*		Psychiatric drug - Other
	Ziprasidone		Psychiatric drug - Other
	Zolmitriptan		Anti-migraine

Wednesday, January 26, 2011

Tox

Thursday, August 26, 2010

Digoxin Toxicity

CCB Toxicity

Beta Blocker Toxicity

Saturday, June 26, 2010

Drugs That Prolong QT

Monday, June 21, 2010

Dabigatran Overdose

Sunday, June 6, 2010

Toxicology Approach

Wednesday, December 3, 2008

Paracetamol Overdose

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